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Retirees Under 65 Plan Information and Forms

Health Insurance

Premium Rates and other  Information Enrollment  and other Forms

Health and Dental Rate Charts

SOS Tools and Resources

Other Resources

Preventive Care Brochures
List of preventive care services covered by Anthem

Quit Smoking Brochure
Under health care reform, you can get certain FDA-approved prescription drugs and many Over the Counter products and nicotine replacement products at no cost to you!

Away From Home Care Program
As a Blue Cross Blue Shield Plan HMO member, Away From Home Care provides healthcare coverage while you are away from your home, such as a child going to college out of state or if you go south for the winter. Read this brochure for more info.

Away From Home Care Participating States
This brochure tells you which states participate in the Away From Home Care program. Click on the state you are going to and it will tell you if that states participates.

Home Delivery Pharmacy Brochure
This brochure provides answers to frequently asked questions regarding Anthem's Mail Order Pharmacy; how to reach them; how to set up Home Delivery Services; etc.

GenericSelect Program
The GenericSelect Program lets you try a generic option on Anthem's list and get that first prescription at no cost.

Urgent Care Brochure
List of walk-in centers and urgent care centers near you.

Anthem's Special Offers
Learn about the many discounts on products and services offered by Anthem.

Anthem's 24/7 Nurse Line
The 24/7 Nurse Line puts you in touch with a registered nurse who can help you decide how to handle a medical issue. Call 800-544-1901.

Anthem's 360 Health Program Brochure
Information on Anthem's Health Programs and Discounts offered for Retirees on Anthem's health insurance plan.


Health Insurance Enrollment/Change Forms

Other Forms

Health & Dental Insurance Declination/Cancelation Form
If you are cancelling your health and/or Dental insurance, or you are retiring and not taking the City's health insurance, you must fill out a Health and/or Dental Enrollment/Change form and this form.

New Hampshire Annuity Deduction Authorization

Fire & Police retirees, you must complete this form if you are making any changes that affect your health and/or your Dental insurance premiums.

Anthem Vision and Medical Reimbursement Form
Use this form to request reimbursement for Vision and Medical expenses paid out of pocket.

Fitness Reimbursement Form and Fitness Log Card
Once you have worked out 48 times during the plan year, submit the fitness reimbursement form and fitness log card or printout from your gym to get reimbursed up to $200 for your gym membership.

Prescription Mail Order Form
Use this form to request prescriptions by mail. The easiest and quickest method is to have your doctor fax it in for you. This information is on the form.

Prescription Drug Claim Form
Use this form if you paid for a prescription out of pocket and need to request reimbursement.

Anthem Individual Authorization Form
Complete this form if you want to allow someone else to be able to make inquires on your behalf regarding your Anthem Health Care concerns and claims.

Anthem Disabled Dependent Form
Complete this form if you want to apply for coverage of your disabled dependent who is over maximum age.

Away from Home Letter & Application Form
Detailed description of the Away From Home program and application form including phone number and mailing address.





Dental Insurance


Delta Dental Outline of Coverage
Brief outline of your Dental Benefits & Dental Coverage Outline.

Delta Dental Plan Booklet
Detailed booklet explaining your dental coverage; what is covered and at what percentage it is covered, etc.

Instructions to Log into Delta Dental
Instructions on how to Log into Delta Dental as a subscriber and how to search for a provider.

Delta Dental Mobile App Brochure
Delta Dental now has a mobile app that will allow you to see your dental information on your mobile device. You must register for Delta Dental on line first. See the instructions to "Log into Delta Dental".

Delta Dental Provider Directory
A directory of participating Delta Dental Dentists.

Delta Dental Vision Discount Program
Free Vision Discount Program offered by Delta Dental. Great savings of up to 35%.

Delta Dental Enrollment/Change Form
Complete this form to make any changes to your dental insurance.

Health & Dental Insurance Cancelation Form
If you are cancelling your health and/or Dental insurance, you must fill out a Health and/or Dental Enrollment/Change form and this form.

New Hampshire Annuity Deduction Authorization Form Fire & Police retirees must complete this form if you are making any changes that affect your health and/or Dental insurance premiums.


Vision and Fitness Reimbursement